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Background: The impact of proactive nutritional repletion in reducing postoperative morbidity in patients undergoing pancreatoduodenectomy (PD) remains poorly understood. This study analyzes the clinical factors which are associated with the utilization of parenteral nutrition (PN) after PD.

Methods: Between 2005 and 2009, 600 consecutive patients who underwent PD were included in the analysis. The most common indications for PD were adenocarcinoma (n=249, 41%), pancreatitis (n=88, 15%), and cystic neoplasms (n=83, 14%). Two-way statistical comparisons were performed between patients who did (+PN) or did not (-PN) receive postoperative parenteral nutrition within 30 days of PD.

Results: Pylorus-preserving PD was performed in 491 patients (82%), and a classic PD in 109 (18%). Operative mortality occurred in 18 (3%) patients. One hundred twenty-two (20%) patients were prescribed PN at a median of 8 days (range, 1-19) after PD. The median duration of PN usage was 9 days (range, 1-246). There were no differences in age, gender, renal function, operative time, or blood loss between the +PN and -PN groups. Patients requiring PN had lower preoperative (2.80 v. 2.93 g/dl, p=0.03) and hospital discharge (2.05 v. 2.32 g/dl, p<0.001) albumin levels. Higher preoperative total bilirubin levels were associated with postoperative PN usage (2.95, +PN v. 2.14 mg/dl, -PN, p=0.02). Operative outcomes with regards to postoperative PN utilization are listed in the table. Forty-seven percent of the patients who developed delayed gastric emptying (DGE) required PN. PD was complicated by a pancreatic fistula (all grades) in 13% of patients, 35% of whom required PN.

Conclusions: Postoperative parenteral nutrition is required frequently in patients undergoing pancreatoduodenectomy. Strong associations between poor nutritional parameters, postoperative morbidity, and PN utilization emphasize the crucial role of adequate nutrition in achieving good surgical outcomes. Establishing enteral nutritional access at the time of PD should be considered in patients at risk for postoperative complications.

Postop PN	All Complications	Major Complications	Re- operation	Pancreatic Fistula	DGE
No (n=478)	198 (41%)	25 (26%)	20 (4%)	51 (10%)	44 (9%)
Yes (n=122)	79 (65%)	68 (56%)	18 (14%)	27 (21%)	39 (32%)
p - value	<0.001	<0.001	<0.01	0.001	<0.001